We Closed the Institutions That Housed the Severely Mentally Ill and We Made It Dramatically Harder to Compel Them to Receive Care

reap as you sow

Every day, it seems, there’s a new story about a person with a serious mental illness randomly attacking someone else. I will not attempt to quantify what’s happening; certainly I don’t think we’re in a crime wave, or a crisis. No, while the cost of these acts of violence for the victims can be very high, sometimes including their lives, the crisis is only really a crisis for the people doing the attacking. And for that reason alone you should want a far more aggressive approach to involuntary mental healthcare than we’ve got, to say nothing about the benefit to public safety. Unfortunately, today’s liberals and soi-disant socialists have a pose that they value more than the do mentally ill people - lol crime, lol crime, lol lol lol. Good little left-of-center people only mock criminal violence, here in 2024, even when the collateral damage is desperately sick people. And so you just can’t talk to them about this stuff. I’ve tried, so hard. All they say is lol crime, lol crime, lol crime.

In 1963, JFK signed the Community Mental Health Act. Its order to close the state psychiatric hospitals was followed, and hundreds were shuttered; the community mental health centers that were meant to replace them were never built. With far fewer beds for a growing patient population it should not have surprised anyone that the streets gradually filled with the severely ill. But somehow, we were surprised. The state governments were mostly just grateful to save money that had once gone to mental healthcare. The passage of Medicaid two years later deepened the problem. Medicaid’s funding structure presented states with an opportunity to further offload costs, this time onto the federal government. Unfortunately, the private institutions that filled with Medicaid patients were no better than the state facilities that had been closed; often they were worse. And maintaining access to Medicaid funding for such care, in practice, was more complicated and less certain than staying in a state institution. In 1975, the Supreme Court’s O’Connor v. Donaldson decision established a national standard that the mentally ill could only be involuntarily treated if they represented an immediate threat to themselves or others. This completely removed actual medical necessity from the equation, and the standard directly incentivized hospitals to discharge very ill patients, many of whom leave these useless emergency room visits and immediately abuse drugs, self-harm, commit crimes, attack others, or commit suicide. In 1990 the passage of the Americans with Disabilities Act further empowered treatment-resistant patients and created legal incentives that led hospitals to release severely ill people rather than face the burden of litigation. Various state reforms in recent decades have almost uniformly pushed the severely ill out of treatment rather than into it, under the banner of “autonomy.” For sixty years we’ve done everything in our power to make it harder to treat people who badly need care. And here we are.

There are desperately ill, utterly impoverished, terribly vulnerable people living on the street right now. They are exactly the kind of people the left should fight for. But because we have become such a caricature of ourselves, we are incapable of acknowledging that some people really are fucked up, that some people really are dangerous, that some people really aren’t just different but are sick, ugly sick, violent sick, no-silver-lining sick. Not beautiful and poetic madness but drug addicted, horrifically paranoid, caked-in-shit sick. And what people like that need is to be forced into treatment to save their lives. But sunny, false notions that everyone muttering to themselves on the subway hides a sweet little self-actualized busy bee inside of them, and an impossibly myopic fixation on the abstract rights of people whose brains have hijacked their minds, has left us unable to provide the actual help the severely mentally ill need. I have found no way to penetrate the liberal consciousness on this issue. Because it’s conservatives, I guess, who complain about violence and disorder on the streets. Because lol crime. So we’re stuck. So are they. Sometimes they shove people in front of subway trains and spend the rest of their lives in prison. Sometimes they get choked to death on subway floors. More often they just moulder in plain sight, stepped over by distracted do-gooder on their way to do good, until they’re found face down in doorways and alleys. There is no feel-good social program that can save them without force; there is no political party that loves them enough to be willing to apply that force to save their lives. So much the worse for them. So much the worse for us.